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Speciality Medicine II > Lecture 3 (Concussion)- Exam 1 > Flashcards

Lecture 3 (Concussion)- Exam 1 Flashcards

1
Q

Concussion Recognition
* If an athlete (or anyone) has an impact to the head or body and complains of what? (6)

A
  • Headache
  • Dizziness
  • Trouble with noise or light
  • Emotion Lability
  • Trouble with memory
  • Feeling “foggy”

You feel that something isn’t quite right with your athlete, student, teammate, or patient.

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2
Q

Increased recognition of CTE and ALS in NFL athletes
* What is CTE?
* Dx how?
* What is the generally found in alzheimer’s disease?
* This build up has been found in who?

A
  • CTE: Chronic Traumatic Encephalopathy
  • Diagnosed post-mortem as a massive buildup of tau protein in neurofibrillary tangles distributed in a unique pattern
  • Absence of the buildup of beta amyloid generally found in Alzheimer’s Disease
  • This build up has been found in 110 of 111 NFL athletes that were studied by McKee

There was an issue with this study

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3
Q

Increased recognition of CTE and ALS in NFL athletes
* What does ALS stand for?
* What is ALS?
* Who was dx with this?

A
  • ALS: Amyotrophic Lateral Sclerosis is commonly referred to as Lou Gehrig’s disease
  • A progressive neurodegenerative disease that causes motor neurons in the body to fail
  • 28 former NFL players have been diagnosed with this condition that has an incidence of 1 in 100,000
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4
Q

Not black and white
* We do not know what?
* We do know what?

A
  • We don’t know the long term effects of concussion
  • We do know the short term effects or symptoms
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5
Q

What is the def of concussion (2002)

A

Concussion is caused by a direct blow to the head, neck or body that results in a rapid onset of symptoms that may not involve loss of consciousness. This condition gradually resolves in a sequential course. It involves a functional disturbance of brain function with grossly normal structural neuroimaging findings.

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6
Q

What were key points from 10 systematic reviews? (4)

A
  • Sport specific interventions
    • SCAT 6 used up to 72 hours
    • SCOAT and child SCOAT
    • Neurocognitive tests should not be used in isolation

Advanced Neuroimaging, Biomarkers and emerging technologies need more research

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7
Q

Key Points
* Updated what?
* WHat is there stong evidence for?
* What is beneficial in the right population?
* Ongoing debate of what?
* The decision to retire an athlete requires what?

A
  • Updated return to learn and sport
  • There is strong evidence for physical activity during recovery
  • Cervicovestibular rehab is beneficial in the right population
  • Ongoing debate exists on long term ramifications of concussion
  • The decision to retire an athlete requires a team and is multifactorial
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8
Q

What is the Neurometabolic cascade?

A
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9
Q

Concussion:Neurometabolic condition
* Calcium?
* Potassium?
* Glucose?
* Blood flow?

A
  • Calcium in the brain increases to 5X normal for up to 3 days
  • Potassium increases by 4 X for up to 24 hours
  • Glucose increases by 2 X during the first 20 minutes after injury
  • Blood flow to the brain can drop by 20%
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10
Q

Neurometabolic Injury
* Immediately after the injury, release of what?
* Massive Neuronal depolarization leads to what?
* In order to maintain the neuronal membrane, what happens?
* What does this require?

A
  • Immediately after the injury, release of neurotransmitters and ionic shifts occur
  • Massive Neuronal depolarization leads to Potassium efflux and Calcium influx into cells
  • In order to maintain the neuronal membrane potential Na-K pumps work overtime
  • This requires ATP which comes from the hypermetabolism of glucose.
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11
Q

Neurometabolic Injury
* ATP must come from what?
* All this is occurring while what?
* increase what?
* Further mitochondrial dysfunction occurs leading to what?

A
  • ATP must come from hypermetabolism of glucose
  • All this is occurring while the body is decreasing blood flow to the brain
  • Increased Lactic acid forms in the brain
  • Further mitochondrial dysfunction occurs leading to Calcium accumulation
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12
Q

Concussion symptoms are caused by what?

A

Concussion symptoms are caused by a metabolic crisis

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13
Q

What is the issue with Imaging for concussion?

A
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14
Q

Biomarkers
* Biomarkers are thought to be what?
* What is a biomarker?
* What is a TBI biomarker?
* Biomarker can be found where?

A
  • Biomarkers are thought to be the FUTURE of concussion diagnosis.
  • Biomarkers: A measurable indicator of some biologic state or condition
  • TBI biomarker: A protein, protein fragment, or enzyme which indicates the presence of axonal injury
  • Biomarkers can be found in blood, CSF, and Saliva
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15
Q
A
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16
Q

Shahim et al.
* Repeated what?
* Who was the population? What was measured?
* What were the results?

A

Repeated studies focusing on Tau protein in Swedish professional hockey players.

250+ players from 12 teams who have blood drawn and Tau and Tau sub-units measured preseason

Results:
-Tau protein is elevated in the blood from baseline in concussed Hockey player
- This elevation correlated with the number of days to return to play

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17
Q

Shahim et al.
* 288 athletes longitudinal study where 105 had a concussion over 3 seasons. What was better at predicting return to play?

A

Neurofilament light was better than tau at predicting return to play

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18
Q

Nitta et al. Neurology
* What was the research about?

A
  • Multiple potential biomarkers were drawn preseason in 857 College and High School athletes
  • 43 athletes had levels drawn at 6 hours, 24 hours, 8, 15 and 45 days
  • IL-6 levels at 6 hours predicted length of symptoms
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19
Q

What are the limiations of biomarkers? (4)

A
  • They take a long tome to analyze
  • Expensive
  • Involve blood draws
  • No large studies looking at the Pediatric population with mild TBI
20
Q

What are the physiologic biomarkers? (3)

A
  • Sleep
  • Movement
  • Heart Rate Variabiity
21
Q

Diagnosis on the sideline
* What is difficult?
* What is important?
* Baseline what?

A
  • Diagnosis of concussion is difficult
  • Knowing the player is often as important as knowing what happened
  • Baseline SCAT testing is important to understand the athletes level of functioning before the injury
22
Q

SCAT-5
* What are the main points that the SCAT-5 look at? (6)

A
  • Maddox: What is going on in the game?
  • Symptom checklist
  • Orientation
  • Immediate Memory (5 words)
  • Recalling three to six numbers backwards
  • Balance testing
23
Q

What are the sxs in concussion?

A
24
Q

Not a Concussion…..
* Patient should not have what?
* Not swelling of what?
* No what?

A
  • Patient should not have Physical Exam findings consistent with closed head injury
  • No swelling of the head
  • No depression or step off
25
Q

Not a Concussion…..
* What is rare?
* Sxs should not?
* Prolonged what?

A
  • Facial injuries are rare but are not likely indicative of further injury
  • Symptoms shouldn’t get worse
  • Prolonged vomiting, loss of consciousness and seizure are not common with concussion
26
Q

Eye movement
* What are different eye mvts/issues? (4)

A
  • Horizontal Pursuit (shaking of eyes)
  • Horizontal Saccades (undershoot at looking at an item)
  • Vertical Saccades
  • Near Point Convergence (6 cm) is off in 24% according to a recent study out of CHOP
27
Q

Memory testing
* What are ways to test memory? (4)

A
  • Serial 3’s or 7’s
  • 5 item recall
  • Months of the year backwards
  • Can be tailored to the patients age
28
Q

What is ImPACT testing?

A
  • Immediate
  • Post-Concussion
  • Assessment and
  • Cognitive
  • Testing
29
Q

IMPACT Testing
* What type of test?
* How long to complete?
* Best what?

A
  • Neuro-Cognitive computer test
  • 20-25 minutes to complete
  • Best concussion management tool available
30
Q

IMPACT testing:
* Why is this the best tool available?

A
  • scores have good reliability
  • Used by NFL, NHL, MLB, and the NCAA
  • Can be used to monitor a patients progression from concussion but the most optimal use is when compared to a players personal baseline
31
Q

Uses of ImPACT
* If baseline testing is available it provides what?
* If baseline testing is not available, repeated what?
* Test scores give what?

A
  • If baseline testing is available it provides reliable evidence of return to baseline
  • If baseline testing is not available, repeated tests can help determine recovery progression
  • Test scores give objective data for Physician and parent discussions
32
Q

IMPACT testing
* What does program measure? (6)

A
  • Attention Span
  • Working memory
  • Sustained and selective attention span
  • Response variability
  • Non-verbal problem solving
  • Reaction time

RAW RNS

33
Q

Gaudet and Weyandt, 2017
* Invalid performance incidence may increase with what?
* _

A
  • Invalid performance incidence may increase with large group versus individual administration, use in nonclinical settings, and among those with Attention Deficit-Hyperactivity Disorder or learning disability
  • Sandbagging
34
Q

What are some other things people are trying to validate? (2)

A
  • Pupillometry
  • EEG
35
Q

Prevention
* Specialized what?
* Most concussion happen when?

A
  • Specialized helmets and headbands have not been shown to decrease concussion
  • Most concussions happen secondary to rotational forces
36
Q

Collar:
* What does the collar do?
* Concept is what?
* No studies on what?

A
  • A collar that compresses the internal jugular vein increasing volume of the brain
  • Concept is decreased movement with impact
  • No studies to show decrease in concussion
37
Q

What is the data on collars?

A

In high school football (male) and soccer players (female) wearing a jugular collar there were no changes on DTI imaging while athletes without collars had changes in DTI even though they were symptom free at the time of evaluation

38
Q

What decreases concussion in hockey?

A

MOUTHGUARDS

39
Q

Alterations in play
* Removal of what?
* Limiting what?

A
  • Removal of checking from youth hockey has led to a 58% decrease in concussion
  • Limiting contact in practice in American football could decrease the rate fo concussion by 64%
40
Q

Linear vs. Rotational forces
* Majority of concussions in the NFL were caused by what?
* In Taekwondo, what is most likely to cause an concussion?
* There is ongoing research about what?

A
  • Majority of concussions in the NFL were caused by hits to the side of the helmet
  • In Taekwondo the hook kick is the most likely to cause concussion
  • There is ongoing research using a variety of methods to measure linear and rotational forces required to cause a concussion
41
Q

So you have a concussion….What do we do?
* Most do what?
* What should you limit?

A
42
Q

So you have a concussion….What do we do

Concentrate on the student-athlete:
* What do you need to do slowly?
* offer what?
* What needs to happen in planned progression?
* Do not take what?

A
  • return to learning slowly
  • Offer accommodations meant to make school more bearable (seating, lights, notes, etc.)
  • make up work in a planned progression
  • Don’t take tests until fully cleared
43
Q

What is the Return to sport in gradual fashion (AT-18)?

A
  • Day 1: Light Aerobic activity (HR <70%)
  • Day 2: Non-Contact Drills
  • Day 3: Complex non-contact drills
  • Day 4: Full contact practice
  • Day 5: Return to play
44
Q

What do you do about 3 weeks out?

A

This is the time where we think about:
- Vestibular Therapy
- Medications
- Other medical issues
- Psychiatric confounders

45
Q

How many is too many concussions?

A
  • We don’t know
  • 2nd concussion in one season
  • 3rd in a year
  • No lifetime maximum but we need to watch for patterns of injury

Speciality Medicine II (11 decks)

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